Inspection on 20/02/07 for 23 Serpentine Road

This inspection was carried out on 20th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

23 Serpentine Road 28/02/06

23 Serpentine Road 14/09/05

23 Serpentine Road 11/03/05

23 Serpentine Road 12/01/05

23 Serpentine Road 11/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Serpentine Road (23) Selly Park Birmingham West Midlands B29 7HU Lead Inspector Kerry Coulter Unannounced Inspection 20th 09:30 Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Serpentine Road (23) Address Selly Park Birmingham West Midlands B29 7HU 0121 472 1722 F/P 0121 472 1722 nazliy@autismwestmidlands.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) autism. west midlands Ms Nazli Yacoob Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 28th February 2006 Brief Description of the Service: The home is a detached residential property situated within the Selly Park suburb of Birmingham. It is close to the Bristol Road, which provides public transport to access shops, parks, pubs, restaurants and places of worship. The main area of the home provides accommodation for four service users with Autistic Spectrum Disorders and Aspergers Syndrome and a attached selfcontained flat for a further service user who enjoys a more independent lifestyle. The main area of the house has four single bedrooms and a staff sleep-in room, which includes WHB and shower. The communal areas consist of a lounge, dining room, large kitchen and extensive garden, all of which the service user who is living in the flat may utilise. The flat has been established from the converted garage and includes lounge, kitchen, bathroom, bedroom and a small laundry. The garden is well laid out and maintained to a high standard and includes a decked area leading directly from the house and garden furniture. The front garden has been converted to off road parking for up to six vehicles. The fees charged as stated in the pre-inspection questionnaire are £1,1261 to £1,700 per week based on the assessed needs of individuals. The fees do not include Toiletries, taxis, magazines and papers, complimentary therapies, dry cleaning, clothing, theatre and concert tickets. The CSCI inspection report is available in the home for those who wish to read it. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, a pre-inspection questionnaire completed by the Manager, completed CSCI comment cards from service users, relatives and health and social care professionals and reports from the provider. One inspector carried out the unannounced fieldwork visit over one day. This was the homes key inspection for the inspection year 2006 to 2007. The Manager and the staff on duty were spoken to. The inspector met with all service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: This is a service that does many things well. There is a clear and consistent care planning system in place to provide staff with information they need to meet service user needs. Staff know what each person likes or dislikes and how they need to support them to have a good quality of life. The systems for service user consultation in this home are good, this includes regular meetings. The home promotes independence and risk taking is based upon an assessment of their individuals needs. Service users are offered a wide variety of activities both within the home and in the community. Each day is planned around what each person enjoys doing and will help them to develop as an individual. Service users spoken with were happy with the choice and quality of food on offer. The home is clean, well decorated and maintained so that is a comfortable place to live in. Service users are supported to go to health appointments and the advice of health professionals is followed to ensure that individual’s health needs are met. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 6 It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. Staff have the training and support they need so that they can meet the needs of the people living in the home and do their job well. Health and safety of staff and service users was well managed. Regular checks of equipment used in the home are done to make sure they are working properly and that the home is safe to live in. What has improved since the last inspection? What they could do better: Service users are involved in the recruitment of staff by meeting each candidate following their interview. Service users then give the Manager feedback on the candidate. Recruitment records did not record their feedback, consideration should be given to doing this to formalise the process to show how their views have been included in the recruitment process. It is strongly recommend that a review of the format of the water temperature records is completed so that they are clearer and easier to understand. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to ensure they can make a choice about whether or not they want to live at the home. Prospective service users individual needs and aspirations are assessed before they move into the home. EVIDENCE: The statement of purpose included all the required information, as did the service users guide. The service users guide was produced using some pictures making it easier to understand. Both documents have been updated to include information about equal opportunities. A new service user handbook has also been completed to include information on complaints, charter of rights, admission procedure, staff selection and adult protection. This has been written by service users (with staff help) and so includes information about the home that the service users who live there think is important. There had been no new service users admitted to the home since the last inspection. Documentation was available to show that the needs of the last service user admitted to the home had been fully assessed before they moved in. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff have detailed information in care plans as to how support each person. Service users are supported to make decisions about their lives. Service users are supported to take risks within a risk assessment framework ensuring they are safe. EVIDENCE: Each service user had a care plan. Sampled plans were seen to be extremely well constructed with detailed information about the levels and type of support required by service users in accordance with their assessed needs. Individual plans also include information about service users preferred routines and the activities they take part in. The service user and their key worker regularly review their care plans. Care plans included service users short and long term goals and how staff are to support them to achieve these. Staff spoken with had a good understanding of the needs of service users and were aware of peoples likes and dislikes. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 11 Daily care records were of a good standard. Staff generally write detailed entries enabling the reader to track all the care provided. During the inspection many positive examples of service users being encouraged, or enabled to participate in the life of the home were observed. This included staff including service users in conversations, and activities such as preparing lunch. From talking to service users and staff, from records and from observations made it is evident that service users can make decisions about their day-to-day lives. Regular service user meetings are held in the home, records of these were available. Areas discussed include activities, holidays, menus and feedback from previous CSCI inspections. The Manager said that to further enable service users to be fully involved in the running of the home they now have their own chosen area of responsibility in the home, with support from staff. Areas include the environment, health and safety, the garden and food safety. It is good that one service user attends part of the staff meeting to feedback from the service user meeting. To ensure confidentiality they do not attend the part of the meeting where staff discuss any personal service user issues. Service users are also consulted via questionnaires as part of the home’s quality assurance system. Service users are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle. Service users records sampled included a risk management plan. These were detailed and included all the risks to the individual and how staff are to support them to minimise the risks. All the risk assessments had been recently reviewed and updated where necessary. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. Service users are offered a healthy diet that meets their special dietary needs. EVIDENCE: Service users records showed that individuals are supported to be as independent as possible. Assessments are completed as to what the individual can do e.g. cooking, cleaning and laundry. From these care plans are developed so that staff know what support the individual needs. Service users are offered a wide variety of activities both within the home and in the community. A vehicle is provided to enable staff to support service users to access the community. Opportunities are available to attend college and go on holidays. Service users said they enjoyed going on holiday. Each service user has a weekly time-table that is a combination of both leisure and activities to develop independent living skills. Activities include shopping, meals out, Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 13 swimming, church, horse riding and recycling. A new computer is available in the dining room for the use of service users. On the day of the inspection several service users were observed playing board games with staff. Other service users said they were going out later with staff to the pub. Service users said that they get to do the things they enjoy. Keyworkers meet monthly with service users to review the activities they have done and what they would like to do in the coming weeks. Service users records sampled showed that they are encouraged to maintain links with their family and friends through telephone calls, letter writing, visits and buying cards and gifts for special occasions. Service users rights are respected. For example, one service user who has epilepsy now has a monitor in his bedroom that is turned on at night so that staff are alerted if he has a seizure. A written protocol is in place to ensure privacy and dignity is respected. Discussion with the service user confirms he has given his permission for its use. Lunchtime practice was observed. There was friendly conversation between staff and service users throughout the meal making it relaxed and enjoyable. Appropriate support was given by staff when needed. Food records showed that a variety of food is offered including fruit and vegetables. Food stocks in the home were plentiful and varied with a choice of fresh fruit available. A lot of fresh vegetables were available in the home. Staff spoken with described how service users plan and choose the menu. Service users spoken with were happy with the choice and quality of food on offer. One commented that he had the opportunity to shop and choose food. Staff at the home have completed training on portion control with the Healthy Eating Coordinator to ensure meals are healthy. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require and their health needs are well met. The management of the medication protects service users and ensures their well-being. EVIDENCE: Service users appearance was very individual in style, age and gender appropriate and reflected their personality. Care plans sampled clearly documented the support that was needed for personal care. Conversations with service users show individuals are supported by staff to shop for their own toiletries. A sample inspection of health records indicates that service users are receiving routine access to general health services, such as well person’s checks, dentist, eye tests and chiropodist. Records sampled showed that staff identify when an individual is unwell and prompt action is taken to ensure that they visit the GP. It is an area of good practice that health action plans have been completed. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. Referrals Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 15 are made to other health professionals as required. Positive feedback was received from health professionals, their comments included- . ‘impressed by the care and support’ and ‘staff are always friendly, polite and helpful’. Some service users are receiving regular input from the dietician and are on healthy eating diets. As part of this they are also taking part in Walk 2000, this encourages regular walks as part of a healthy lifestyle. It is good that one service user has been supported by staff to meet their target weight. The dietician said that ‘‘Staff and service users have worked really well to implement ‘healthy lifestyles’. The system for the administration of medication is satisfactory. Medicines were seen to be stored appropriately in a secure location. Stock checks are completed on a regular basis and copies of prescriptions are retained. Sampled medication administration records were appropriately completed. Where required, protocols were available for ‘as required’ medications to guide staff as to when medication should be administered. Homely remedy protocols detailed what each individual could take with their prescribed medication and when these should be given. The Inspector was informed that all staff who administer medication have received accredited training from Solihull College. The Manager also does regular observations of staff administering medication to ensure that service users receive their medication safely. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know how to make a complaint and that their views will be listened to and acted on. Arrangements are sufficient to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure included all the relevant and required information so that service users and their representatives know how to make a complaint. Each service user has a charter of rights checklist- as part of this they have signed to confirm they have received a copy of the complaints procedure. Some service users have been involved in writing information about making a complaint and what is abuse and what to do about it. This has been put in a handbook and is written in a way that the service users understand. Keyworkers meet monthly with service users to discuss any issues that are important to them and to check that they are happy. Service users said they would speak to staff if there was something they were not happy about. Staff said that they could raise any concerns they had with the Manager as she always listens and responds. The pre-inspection questionnaire stated that there have been no complaints made in the last twelve months. Compliments had been received about the home and these were recorded. Two service users financial records were looked at. Service users money is stored securely in the home. Money held for individuals cross-referenced with the amount stated on their financial records. Receipts are kept of all expenditure. Records showed that service users spend their money on personal items and not on things that should be provided from the fees that they pay. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 17 Training records showed that all staff had received training in adult protection and the prevention of abuse. Individual detailed behaviour management strategies were in place where needed for some service users so that staff know how to respond to their behaviour. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: There is a range of communal space available to include a large kitchen, dining room and lounge. One resident has a self contained flat which includes kitchen facilities. The home has a large garden that includes a ‘decked’ area. This can be accessed via the dining room. The home operates a no smoking policy, however a covered area in the garden is provided if service users wish to smoke outside. Most areas of the home have been repainted since the last inspection to include lounge, dining room and bedrooms. Service users confirmed they had chosen the colours. New furniture has also been purchased for the lounge to include seating, curtains and mirror making this a nicer place in which to spend time. It is good that since the last inspection an attempt has been made to Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 19 blend in the metal staff lockers in the dining room. They have been repainted the same colour as the décor making this room more homely. Each service user has their own bedroom. Service users bedrooms seen were decorated according to individual tastes and interests and were personalised. There were photographs and pictures around their bedrooms and service users said they had been involved in choosing the decoration for their bedroom. At the last inspection it was recommended that a review of the number of notices on display was done as there were too many, this spoilt the homely feel of the environment. This has been done and some notices have been removed. Infection control procedures were satisfactory. The home was clean. Food in the fridge was date labelled and records of fridge/freezer temperatures evidence that food is stored at safe temperatures. The laundry is situated in a separate area in the hall. A cleaning schedule is in place to ensure staff clean all areas of the home on a regular basis. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well trained and supported staff team that can support them to meet their individual needs and achieve their goals. Service users are protected by the home’s recruitment practices. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. Seven out of the thirteen staff have completed an NVQ 2 or 3 in care, this meets the standard of having at least 50 of staff having completed an NVQ. Positive comments were made by relatives about the staff, this included ‘exemplary staff’. Service users said ‘staff are always helpful and nice’, ‘staff always listen’. Staff spoken with were very knowledgeable about the needs of individual service users and were extremely enthusiastic about their jobs. One staff said they found it very rewarding to work at this home. Satisfactory levels of staff are on duty to meet service users needs. Staffing levels vary depending on the activities planned for that day, and are therefore flexible to meet the needs of the service users. There is one staff vacancy that is being Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 21 covered by an agency staff on a long term contract. The Manager said that this is done to ensure service users are supported by someone they know well, rather than lots of different agency staff who they do not know. Staff records included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken to ensure that suitable people are employed to work with the service users. The Manager said that service users are involved in the recruitment of staff by meeting each candidate following their interview. Service users then give the Manager feedback on the candidate. Recruitment records did not record their feedback, consideration should be given to doing this to formalise the process. The Manager has developed an organised system for the tracking of training received by staff. A printout of each topic records the date and the staff who attended, with copies of the certificates available in staff files. Records evidence that staff receive the training they require to effectively meet the needs of service users. Staff records showed that they had received training in adult protection and the prevention of abuse, moving and handling, first aid, fire safety, Safe Handling of Medicines, food hygiene, equal opportunities, health & safety, Studio III (a recognised form of physical intervention) and autism. Staff spoken to showed knowledge of individual service users needs, likes and dislikes. Staff said that they had received regular training and this is renewed every year so they keep up to date. The home has been awarded the Investors in People award, this recognises the training and support systems in place for staff. Records sampled showed and staff said that they have regular, formal recorded supervision sessions. Regular staff meetings are held and minutes of these are kept. Staff said that they have the opportunity to raise things in staff meetings and can put items on the agenda if they want to. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 41 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Manager communicates a clear sense of direction so that individual’s needs are well met. Service users views underpin all self-monitoring, review and development of the home. Service users health and safety is promoted and protected. EVIDENCE: The Registered Manager has several years experience of managing a care service for people who have autism. They were observed to know the individual service users well and how to meet their needs. Staff spoken to said that the Manager is very supportive and they felt at home working there and felt comfortable to voice their opinions. The Manager is very keen to improve the quality of service, always looking and listening for new ideas from service users and staff. Service users surveys record ‘ I like the way the home is being run’. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 23 The Manager has demonstrated ongoing compliance with recommendations made at previous inspections. The Provider’s representative completes monthly visits to the home as their responsibilities under Regulation 26 and writes a report of this. The reports of the visits consider the views of service users. Over the last year the Manager has continued to develop her own quality assurance system and this is now becoming an excellent tool for ensuring the views of service users are taken into account when developing the service. Areas covered include audits of the number of accidents and incidents, complaints and compliments, CSCI inspection reports, feedback forms from service user on activities undertaken, feedback from visitors, feedback from relatives, service user consultations, staff feedback forms, and staff sickness levels. All this information is analysed and service users views play an important part. The information is used in completing development plans for the home. A Health and Safety audit was done by an external company in September 2006. Actions have been have taken where risks were identified. The report from this records standards are generally very good. A recent West Midlands Fire Service inspection records that the fire precautions are satisfactory. Fire records showed that regular fire drills are held so that staff and service users know what to do if there is a fire. Staff regularly test the fire equipment to make sure it is working. An engineer regularly services the fire equipment. A Corgi registered engineer completed the annual test of the gas equipment in November 2006 and stated that it was in a satisfactory condition. An electrician completed the five yearly electrical wiring test in 2005 and stated that it was in a satisfactory condition. Risk assessments were available for the premises, food, staff, fire, moving and handling and hazardous substances. These were all regularly reviewed and updated where necessary. An external company is employed to check the water temperatures monthly to ensure they are at the correct temperature and service users are not at risk of scalding. The records completed are quite confusing and difficult to assess that water temperatures do not exceed 43 degrees, it was also confusing and difficult to find records for the bath water temperatures. Hand testing of the water in the home showed that they were at safe levels. It is recommend that a review of the format of the records is completed so that they are clearer. Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 4 4 X X 3 X Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations Service users are involved in the recruitment of staff by meeting each candidate following their interview. Service users then give the Manager feedback on the candidate. Recruitment records did not record their feedback, consideration should be given to doing this to formalise the process. It is strongly recommend that a review of the format of the water temperature records is completed so that they are clearer and easier to understand. 2. YA42 Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Serpentine Road (23) DS0000016961.V333009.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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